Running head: THE ETHICS OF DIAGNOSES

The Ethics of Diagnoses Student Name: Dermot Connolly Stenberg College Surrey BC 0312 NURS 104-3 (A) Kyle Taylor Jan 18th 2013.

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Abstract This paper examines the ethics of diagnosis in mental health and in particular, the effects such a diagnosis can have on a patient who has being misdiagnosed. The ethical responsibilities of the psychiatrist and physician are also called into question where their moral and ethical responsibilities are defined. This paper will focus on three key ethical issues surrounding mental diagnosis; the relationship between stigma and diagnosis, the validity of using the DSM to make a psychiatric diagnoses and the development of disease mongering, where the definitions of mental illnesses are stretched to allow for the exaggeration of symptoms and marketing of drugs. Keywords: ethics, diagnoses, DSM, disease mongering.

THE ETHICS OF DIAGNOSES The Ethics of Diagnoses From my experience working with acute psychiatric patients, I have noticed a recurring feeling of injustice among many involuntary patients. Many have spoken out against their diagnoses and of their belief that they have being incorrectly or misdiagnosed. For many, the diagnosis of mental illness has labeled them as being unstable resulting in them being

marginalized by their community. The purpose of this discussion is to cast a critical eye over the diagnosis of mental illness paying particular attention to the ethics involved. This investigation will also examine the contribution diagnoses plays in disease mongering and stigmatization of mental illness. Attention will also be given to the DSM itself calling into question, the validity of many of its diagnosis. In 1840 the US census contained just one diagnosis for mental illness. The 1917 edition of the American Psychiatric Association contained 59 diagnoses for mental illness. By 1980, that number had risen to 227 and today the diagnostic and statistical manual of mental disorders has listed 347 diagnosed mental illnesses. The London Philosophy Club (n.d.). We may ask way this number has increased so dramatically over such a short period of time? Has research into psychiatric illness evolved at such a rate that we are now in a position to diagnosis and treat more psychiatric disorders? Or is it simply that we cannot accurately diagnoses a psychiatric disorder in the absence of quantitative data and instead resort to unscientific methods to compartmentalize the mentally ill to appease the pharmaceutical companies and many other sections of society? It is an unfortunate reality that in todays society, the diagnoses of a mental illness, carries with it many stigmas. Consumers of mental health services frequently experience embarrassment, shame and judgment, which often makes them a target for discrimination, and

THE ETHICS OF DIAGNOSES ridicule within society. (Martin & Johnston, 2007). Mental illness stigma compartmentalizes individuals into sections of society which play an important role in defining their status within that community. Over time, this compartmentalization influences how they are viewed by their peers and ultimately by themselves. (Martin & Johnston, 2007). Some studies reveal that as many as 75% of sufferers feel they have being ostracized by other members of their community

because of their mental diagnoses. (Laurance, 2012). Perhaps more disturbing is the fact that this stigma permeates to the patients themselves, resulting in the development of negative feeling towards their own diagnosis. The patient comes to expect poor treatment and rejection where they develop coping strategies such as withdrawal, designed to protect themselves from such stigmas. (Martin & Johnston, 2007 p9). Courtesy stigma (Martin & Johnston, 2007 p9), is the term commonly used to describe the stigma displayed by those of us who interact with a patient of mental illness and include both mental health professionals and family members. (Martin & Johnston, 2007). Such stigma manifests itself in an us vs. them mentality which only reinforces the perception that mentally ill patients are different and should be treated as such. (Martin & Johnston, 2007). In fact some studies have demonstrated that the stigma of mental illness and in particular depression is prevalent among medical students where stress levels are high. (Chavis, 2010). Studies such as these have shown that students suffering from depression feeling highly stigmatized not only by their fellow students but also by other faculty members. Often times this can result in the student failing to seek medical help because they fear that it will perceived as an inability to cope and impact their future options. (Chavis, 2010). There are even some suggestions that believe the stigma attached to a mental illness is worse that he illness itself. (Laurance, 2012).

THE ETHICS OF DIAGNOSES To help eliminate the impact stigma plays on mental illness, a three pronged approach has being proposed that includes public education, highlighting discrimination, and familiarity with mental health suffers (Martin & Johnston, 2007). When considering education, normal emotional functionality and maintenance of professional care are just two of the topics which healthcare providers should be taught as part of their ethical and professional responsibility. (Chavis, 2010). While many reports highlight the ineffectiveness of government action in tackling stigma (Laurance, 2012), greater awareness needs to be placed on other considerations such as the importance of making ethically sound judgments when diagnosing a patient with

mental illness. As mental health professionals, it is important therefore to recognize the impact a mental health diagnosis can have on a patient and to consider our moral and ethical responsibilities when we feel this diagnose has being abused. Such moral responsibility has its roots in ethical theory which acts as moral guides to help us determine right from wrong and how best to act. (Butts & Rich, 2005). With respect to stigma, often times society fails to practice their virtue ethics which calls on the character of the individual to stand up against perceived injustice. (Butts & Rich, 2005). In terms of diagnosis, such moral responsibility can take the form of a physician; psychiatrist or psychiatric nurse calling into question the diagnoses of a patient they believe has being misdiagnosed. With so many people suffering from different types of illness both physical and mental, it is comforting to know that the mental health profession is available to help. We like to assume that when a person is diagnosed with a mental illness that the diagnoses is accurate and correct. We assume they will receive the correct treatment, make a full recovery and return cured to their families. Caplan, (n.d). For many however this is a false assumption. For many, the diagnoses of a mental illness causes more stress and trauma than they had prior to their diagnoses. Caplan,

THE ETHICS OF DIAGNOSES (n.d). The inability to make decisions about your own illness, the stigma and the potential to overlook physical factors are all challenges attributed to a person diagnosed with a mental illness. Caplan, (n.d). To add further insult, the diagnosis of a psychiatric illness, unlike psychiatric drugs is not regulated. Caplan, (n.d). This should be very concerning to all psychiatric patients, especially as more often than not; the diagnosis of a mental illness is highly subjective. Caplan, (n.d). In 1996, Paula Caplan published her book They Say Youre Crazy in which she demonstrates the American Psychiatric Associations (APA) inability to accurately diagnose mental disorders on any scientific basis. (Grohol, 2002). Caplan worked for many years as a psychotherapist before being hired as a consultant by the APA. During this time, she became increasingly disillusioned with the process of defining what it means to be normal and abnormal in psychiatric terms. She talks specifically of the inevitability of mistreatment following the diagnoses of a mental illness, which she says is done without any sense of responsibility or humanity. (Caplan, 1999). Caplans biggest concern lies in how the APA diagnoses mental illness. Using research she calls deeply flawed (Caplan, 1999 para 14), Caplan suggests the APA is misdiagnosing mental illness within its diagnostic and statistical manual of mental

disorders (DSM) which is being utilized by psychiatrics the world over to diagnose their patients. (Caplan, 1999). In fact she suggests that when proper reviews of mental illness are conducted, many of the findings indicate problems with daily living as opposed to mental illness. (Caplan, 1999). There is a significant ethic issue at play here. The psychiatrist has a deontological ethical responsibility to provide the best possible psychiatric care to their patients. (Butts & Rich, 2005).

THE ETHICS OF DIAGNOSES This is difficult to achieve in the absence of any scientific data to justify their diagnosis. Often,

when mental health professionals are interviewed, they refer to the DSM as justification for their diagnosis without realizing that the diagnosis is politically motivated and inaccurate. (Caplan, 1999). Scientific investigation for example is used to describe clinical investigations which are no substitute for laboratory based data. (Sobo, 2013). The use of the term evidence based treatment options is also called into question which indicates that such treatments are rooted in scientific based data when often times they are not. (Sobo, 2013). The improper or misdiagnoses of psychiatric illness has also helped fuel the growth of disease mongering. Disease mongering is the term used to describe the selling of sickness by fudging the definitions of many of todays diseases and illnesses. (Moynihan, Doran & Henry 2008). The purpose of disease mongering is to artificially overinflate the pharmaceutical market so as to sell medication to healthy people through misdiagnoses. (Moynihan, Doran & Henry 2008). In addition to the ethical issue of deontology, disease mongering also wastes resources and places the patient at greater risk of injury (Moynihan & Henry 2006). Research has identified different types of disease mongering targeting different types of illness, some of which are part of the natural aging process. Illnesses such as menopause for example are natural targets for disease mongering. (Moynihan & Henry 2006). While other mild illnesses are promoted as being more serious than they are, such as irritable bowel syndrome. (Moynihan & Henry 2006). Another form of disease mongering, classifies risk factors as diseases such as osteoporosis and high cholesterol. (Moynihan & Henry 2006). Pharmaceutical companies however do not work alone in the promotion of disease mongering. Doctors and

THE ETHICS OF DIAGNOSES patient advocate groups also promote its basic principles onto the media and policy makers to help generate interest and advocate for policy changes. (Moynihan & Henry 2006). Of particular interest to the mental health industry is the clever attempt to sell bi polar disorder to the public. Research into many of the commercials surrounding bipolar disorder; seem to encourage awareness through the promotion of information, websites and phone numbers. (Healy, 2006). Many of these commercials do not appear to be promoting any medication until you make contact with the information options provided. Suddenly, what appeared to be public information commercial, has turned into the promotion and selling of bi polar medication. (Healy, 2006). Another example of disease mongering of bi polar disorder, is the use of mood stabilizers. Since the 1950s bi polar depressive episodes were controlled through anti depressants and manic episodes through antipsychotics such as lithium. (Healy,

2006). Prior to 1995 the term mood stabilizer was not associated with bi polar disorder, but by 2001 it was a common term used in many medical journals. (Healy, 2006). Judging from the use of the term, it became apparent that there was no consensus among medical circles as to what the term effectively meant. However, this did not stop the promotional message that mood stabilizers should be prescribed for all patients suffering from bi polar disorder, and in many cases, should be administered in place of any other psychiatric medication. (Healy, 2006). Patience is needed for those who wish to wage war on disease mongering, for it is a daunting task. It is an industry controlled by multinational pharmaceutical companies, politics and economics. (Heath, 2006). In order to tackle such an industry, one must first understand what fuels it. At its very heart, disease mongering feeds off people fears of dying. In the past, these fears were accepted somewhat where death did not mean the end of life, merely the

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beginning of the afterlife. (Heath, 2006). In todays society, more people have turned their backs on religion and for them death is the inevitable end of life which must be delayed. (Heath, 2006). By understanding what feeds the industry, we must turn to the ethical virtues of the people in order to defeat it. (Heath, 2006). Within each of us lies the excellence of character to recognize immoral acts. Only through appealing to peoples sense of virtue can we every truly win the war against disease mongering. Over the past 150 years, the number of mental illnesses diagnosed in the US has increased at a staggering rate. Such an increase has called for analysis into the methods used to make such diagnoses. It is the opinion of this writer that such analysis invites healthy debate and critical assessment into the criteria used to diagnoses mental illness. Psychiatrists and physicians must take on board their ethical responsibility when diagnosing a patient with a mental illness, where such a diagnoses carries with it a label of perceived instability resulting in society stigmatization. Psychiatric policy makers are also invited to view the validity of psychiatric diagnoses in the absence of quantitative data. Questions such as why the DSM alone is used to diagnose psychiatric illness in an industry largely influenced by disease mongering promoted by many pharmaceutical companies is just one of the questions that need to be answered?

References: Butts, J.B, & Rich, K.L. (2005). Introduction to Ethics in Nursing. Introduction to Ethics in Nursing. (p. 1-28). Retrieved from http://stenbergcollege.mrooms3.net/course/view.php? id=459

THE ETHICS OF DIAGNOSES Caplan, P., J. (1999). They say youre crazy. Retrieved from: http://www.sntp.net/references/normal.htm Caplan, P., J. (n.d). Psychiatric Diagnosis: Too Little Science, Too Many Conflicts of Interest. The Association for Women in Psychology. Retrieved from:

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http://www.awpsych.org/index.php/bias-in-psychiatric-diagnosis-dsm-v-portal/74-biasin-psychiatric-diagnosis-dsm-v/bias-in-psychiatric-diagnosis-dsm-v/101-psychiatricdiagnosis-too-little-science-too-many-conflicts-of-interest Chavis, S. (2010). Depression stigma higher in medical students, Psych Central. Retrieved from: http://psychcentral.com/news/2010/09/21/depression-stigma-higher-in-medicalstudents/18468.html Grohol, J., M. (2002). They Say Youre Crazy. Psych Central. Retrieved from: http://psychcentral.com/lib/2002/they-say-youre-crazy/ Healy, D. (2006). The latest mania: Selling bipolar disorder. PLOS Medicine. Retrieved from: http://www.ploscollections.org/article/info%3Adoi %2F10.1371%2Fjournal.pmed.0030185;jsessionid=BFE5658C824D05F2B2138F5CCF7 0AC11 Heath, I (2006). Combating disease mongering: Daunting but nonetheless essential. PLOS Medicine. Retrieved from: http://www.ploscollections.org/article/info%3Adoi %2F10.1371%2Fjournal.pmed.0030146;jsessionid=BFE5658C824D05F2B2138F5CCF7 0AC11

THE ETHICS OF DIAGNOSES Laurance, J. (2012). Stigma of mental ill health is worse than the illness. The Independent. Retrieved from: http://www.independent.co.uk/life-style/health-and-families/healthnews/stigma-of-mental-ill-health-is-worse-than-the-illness-8215750.html Martin, N. & Johnston, V., (2007). A time for action: Tackling stigma and discrimination. Mental Health Commission of Canada. Retrieved from: http://www.mentalhealthcommission.ca/SiteCollectionDocuments/AntiStigma/TimeforAction_Eng.pdf

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Moynihan, R., Doran, E. & Henry, D. (2008). Disease mongering is now part of the global health debate. PLOS Medicine. Retrieved from: http://www.plosmedicine.org/article/info %3Adoi%2F10.1371%2Fjournal.pmed.0050106 Moynihan, R., & Henry, D. (2006). The fight against disease mongering: Generating knowledge for action: PLOS Medicine. Retrieved from: http://www.ploscollections.org/article/info %3Adoi %2F10.1371%2Fjournal.pmed.0030191;jsessionid=BFE5658C824D05F2B2138F5CCF7 0AC11 Sobo, S. (2013). The strengths and weaknesses of DSM IV: How it clarifies, how it blinds psychiatrists to issues in need of investigation. Retrieved from: http://simonsobo.com/thestrengths-and-weaknesses-of-dsm-iv The London Philosophy Club (n.d.). LPC talk and debate: The ethics of psychiatric diagnosis. Retrieved from: http://www.londonphilosophyclub.com/events/89399802/? eventId=89399802&action=detail

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